An excellent review of the current British military practice to prevent and treat the acute coagulopathy of trauma shock (ACoTS) describes pathophysiology and treatment options and offers an algorithm for management. Key components of the system (when indicated according to their algorithm) outlined include:

Pre-hospital damage control shock resuscitation by a forward medical team, consisting of RSI with reduced dose thio or ketamine with suxamethonium or rocuronium, large bore sublclavian access, and early use of warmed blood products

1:1:1 packed red cells, fresh frozen plasma, and platelets,

Cryoprecipitate

Tranexamic acid

Recombinant activated factor VII

Permissive hypotension aiming for a systolic BP of 90 mmHg, using blood products and avoiding vasopressors according to a ‘flow rather than pressure’ philosophy

Buffering acidosis using Tris-hydroxymethyl aminomethane (THAM), which may be superior to bicarbonate by not affecting minute ventilation or coagulation, and maintaining its efficacy in hypothermic conditions

Minimising hypoperfusion with an anaesthetic strategy that provides effective analgesia and vasodilation, using high dose fentanyl and a low concentration volatile agent